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Child Neuropsychology

A blog by Dr Jonathan Reed

  • There is a very interesting debate in the US at the moment about how to tackle reading problems (dyslexia). There is increasing interest in the Response to Instruction (RTI) approach- summarized here. This approach focuses on how to teach reading for everyone rather than just identifying and treating children with dyslexia. It is a public health approach focusing on prevention rather than an individual disorder approach focusing on treatment. In the UK the focus is more individual and based on clinical identification of dyslexia- i.e. does this person have dyslexia or not. Parents and teachers need to find someone – often a clinical or educational psychologist to diagnose dyslexia. This in turn depends on the parent or teacher recognizing the problem in the first place and many children seem to slip through the net. The psychologist will normally write a report with recommendations, which in my experience are often not followed. It is an inefficient system. The RTI approach seems to be more about looking at the school population as a whole. They screen the whole school population at a young age and then the children identified with delayed reading are either provided with minimal intervention or if this doesn’t work more intensive intervention. The focus is on how reading is taught (instruction) and how the child responds to this instruction rather than identifying disability. The research findings suggests that instruction accounts for a lot of reading difficulty and there is a large body of impressive research looking at the effectiveness of RTI- see this site for details. There is a reaction from some neuropsychologists who feel that RTI doesn’t address children with more severe deficits and more complex neuropsychological profiles- RTI is a bit of a catch all that misses the more unusual kids. Also there is concern about the use of RTI in practice. Whilst as a neuropsychologist I have some sympathy with this view I feel more strongly that children should be leaving school being able to read especially when the research shows that nearly all children can be taught with the right teaching methods-see previous posts on dyslexia. I don’t think we have got it right in the UK and too many children are failing. I really like the public health aspect that RTI advocates. If a smaller group of children who need further assessment and more intensive intervention could be identified using this approach and that there are then clear referral lines to a psychologist, it would be a better use of resources and may prevent a lot of children having a miserable and unproductive time at school. It should theoretically be possible to eliminate nearly all reading difficulties in the UK. I am aware of the inspiring work of Tommy Mackay who virtually eliminated reading difficulties in one school district in Scotland, but I am not aware of this happening in other places in the UK or of a political will to address this. I would be keen to learn of other people’s experience of this and any other thoughts- please post a comment.

  • My early career involved working with patients with multiple sclerosis (MS) and undertaking research into how people cope with this. This experience left a lasting impression as MS is a horrible disease to live with. It is neuro-degenerative disorder resulting in progressive loss of function leading to both both physical and neuropsychological disability. There are different forms with some slow moving and some with very rapid deterioration. MS results in the destruction of the myeline in the brain. Myelin is the substance that coats and insulates brain cell in a similar way to the way that plastic coating insulates electric wiring. When the myelin is destroyed the brain short circuits. Whilst most people associate MS with older adults there is an early onset version affecting children and adolescents which is particularly devastating.

    When I was working in the area a key puzzle was the geographical distribution of MS. It becomes more prevalent the further North you go. It is far more prevalent in Scotland for example, than it is in Southern Europe. Recent speculation has been that sunshine and as a result levels of vitamin D may be the reason for this geographical distribution A recent research study by Ramagopalan et al and published in PLoS Genetics has started to show in more detail the possible causal factors. They have identified a gene HLA-DRB1 that is associated with MS. More interestingly they found that vitamin D interacts with HLA-DRB1*1501 and effects whether this gene is expressed i.e the vitamin D influences whether the gene is switched on or off.

    As well as identifying possible causes of MS I think this work is important as it shows the way that genes and environment can interact in neurology and neuropsychology. Genes are not totally deterministic i.e. that there is nothing you can do if you have the relevant gene. Factors in the environment can influence whether a gene is expressed. Therefore by changing the environment or behaviour we may be able to prevent genetic neurological and neurodevelopmental disorders from occurring. In the future it may be possible to screen for all genetic risk factors and then to change behaviour or take supplements to prevent neurological illness and disorder developing. In the case of MS it may be that supplementing vitamin D or exposure to sunlight for people with the deviant gene at the right critical period, can prevent the onset of MS and thus prevent a lot of distress.

  • One of my favourite columnists from The Times newspaper Daniel Finkelstein has written a thought provoking column today criticizing the latest report The Good Childhood Enquiry. This report was about how unhappy children are today because of selfish parents. In the column Daniel makes some simple points which I often think about myself when seeing children. The key issue is the extent to which parents influence children’s behaviour and personality. The points he makes are 1- children and parents share the same genes and therefore are likely to be somewhat alike to start with. 2- children who are difficult are going to influence the way their parents react to them. It is easy to be an authoritative parent with a child who is easy to manage- the traffic is not all one way. I happen to believe that parents do have an affect on their children but there are so many other issues affecting development as well. The issues about genetics that Daniel raises are penitent as well as the effect of the peer group, diet, sleep, exercise, brain injury, neurodevelopmental issues etc etc. Finally the column ends with an interesting take on the pros and cons of individualism and it’s effect on social relationships – but you will have to read that HERE yourselves.

  • A new study on the benefits of stem cell therapy in patients with multiple sclerosis is a very exciting one for all neuroscience. The study shows that by giving stem cells to MS patients, disability is halted or reversed. The study included measures of neuropsychological function as well as neurological rating scales and quality of life. Improvements in these areas were seen in 17 out of 21 patients and there was no deterioration in the other 4. The reason why it is so important lies in the use of stem cells. The problem with all neurological disability including childhood brain injury is that the brain can not repair itself. This is to do with the way the brain develops. The brain starts to develop at 40 days old with stem cells lining the neural tube. The stem cells turn into precursor cells, then blast cells and then specialized neurological cells. The whole process lasts until the fetus is approximately 6 months old. It is an amazing process with cells developing at the rapid rate of approximately 250,000 a minutes. However, by the end of six months the process stops and you are left with the brain that will last you the rest of your life. If you damage the cells in your brain they will not grow back in the same ways as skin and bone cells would. This is the reason why neurological injury is so hard to treat. If, however, we can replicate the natural development process by using stem cells the possibility is there to treat all neurological disability. It is still early days in terms of this research but these findings are very encouraging. A major problem has been that you basically need to use embryos to produce the stem cells. The recent Bush government in the US was against this on religious and moral grounds. There are however, some new discoveries now in using adult stem cells from different areas of the body. Also it is believed that Barak Obama will allow the stem cell research to start again. Just recently the FDA in the US approved use of stem cells in human medical trials for spinal chord injury. If the research does take off and if these early research findings are replicated there is the very exciting prospect of new treatments for neurological disability in the future.